Individual Ergonomics Evaluation
Company Name
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
Ergonomics Consultant
First Ergonomics Evaluation
Yes
No
Reason for Evaluation
Office sweep
Prevention
Request for furniture/accessories
Discomfort/Pain*
Other
Area of discomfort/pain
Head/headache
Neck
Shoulder(s)
Upper back
Mid back
Lower back
Elbow(s)
Forearm
Wrist
Finger(s)/Thumb(s)
Hips
Leg(s)
Knee(s)
Ankle(s)
Foot/feet
Other
* Further details: Discomfort/Pain (how long have you had the pain for, frequency, present when away from work, tx etc.)
Mousing Hand
Right
Left
Both
Height
Touch Typist
Yes
No
Desk (main workstation)
Fixed height sitting desk
Fixed height standing desk
Sit-stand desk (crank)
Sit-stand desk (electric)
Other
Chair
Keyboard
Mouse
Screen Setup
Laptop only on the table
Laptop only on a riser
1 x monitor
1 x monitor and laptop on the table
1 x monitor and laptop on a riser
2 x monitors
2 x monitor and laptop on the table
2 x monitors and laptop on a riser
Other
Other work spaces
Soft seating space
Cafe
Meeting rooms
Home
On the move
Other
Other Accessories
Footrest
Laptop riser
Document holder
Lumbar support/cushion
Desk phone
Headset/headphones
Monitor riser
Monitor arm
Keyboard wrist rest
Mouse wrist rest
Other
Other work spaces - further information:
Typical Work Routine (Daily working hours, meetings, breaks, sitting/standing, working from home, travel etc.)
Before evaluation photo
Potential postural issues - Desk
Nil issues
Sitting - too high
Sitting - too low
Standing - too high
Standing - too low
Other
Potential postural issues - Chair
Nil issues
Chair too high
Chair too low
Insufficient back support
Seat pan too long
Seat pan too short
Other
Potential postural issues - Screens
Nil issues
Laptop too low
Monitor(s) too low
Monitor(s) too high
Too far
Too close
To the side
Other
Potential postural issues - Keyboard (including laptop keyboard)
Nil issues
Keyboard too far
Keyboard too close
Wrists deviated while typing
Other
Potential postural issues - Mouse
Nil issues
Mouse too far
Mouse too close
Mouse too small
Wrists deviated while mousing
Other
Changes made during evaluation
Chair adjusted
Desk adjusted
Keyboard adjusted
Mouse adjusted
Monitor adjusted
Laptop adjusted
Temporary footrest added
Temporary laptop riser added
Other
Additional changes made during evaluation
Education given
Neutral posture - sitting
Neutral posture - standing
Tips laptop use
Tips for mobile phone use
Working on the move/ remotely
Methods to prevent discomfort
Home office set up
Micro-breaks
Movement and mobility
Eye care
Causes of pain/discomfort/MSD
Desk stretches
Other
Product recommendations
Break reminder software
Laptop riser
Footrest
Document holder
Monitor riser
Monitor
Standard keyboard
Standard mouse
Ergonomic keyboard
Ergonomic mouse
Anti-fatigue mat
Keyboard wrist rest (standard)
Keyboard wrist rest (slim)
Mouse wrist rest
Sit-stand desk converter
Desk lamp
Keyboard tray
Other
Further details on product recommendations
Furniture recommendations
After Evaluation Photo
Any other details
Submit
Should be Empty: